Abstract
A growing body of literature suggests combining organizational ethnography and case study design as a new methodology for investigating complex organizational phenomena in health care contexts. However, the arguments supporting the potential of organizational ethnographic case studies to improve the process and increase the impact of qualitative research in health care is currently underdeveloped. In this article, we aim to explore the methodological potentialities and limitations of combining organizational ethnography and case study to conduct in-depth empirical health care research. We conducted a scoping review, systematically investigating seven bibliographic databases to search, screen, and select empirical articles that employed organizational ethnographic case study to explore organizational phenomena in health care contexts. We screened 573 papers, then completed full-text review of 74 papers identified as relevant based on title and abstract. A total of 18 papers were retained for analysis. Data were extracted and synthesized using a two-phase descriptive and inductive thematic analysis. We then developed a methodological matrix that positions how the impact, contextualization, credibility, and depth of this combined methodology interact to increase the generative power of in-depth qualitative empirical research in health care. Our review reveals that organizational ethnographic case studies have their own distinct methodological identity in the wider domain of qualitative health care research. We argue that by accelerating the research process, enabling various sources of reflexivity, and spreading the depth and contextualization possibilities of empirical investigation of complex organizational phenomena, this combined methodology may stimulate greater academic dynamism and increase the impact of research. Organizational ethnographic case studies appear as a new in-depth qualitative methodology that both challenges and improves the conventional ways we study the lives of organizations and the experiences of actors within the interconnected realms of health care.
Keywords
Introduction
Organizational ethnography is currently attracting increased interest in social and organization studies (Aguinis et al., 2019; Berthod et al., 2018; Bryman & Buchanan, 2018; Hammersley, 2018; Prévost & Roy, 2015; Van Maanen, 2002, 2006). According to Berthod et al. (2018, p. 1), this methodological approach is “regularly pushed to the fore as one of the most revered approaches to qualitative research.” While there is currently no consensus of the definition of ethnography per se in social and organizational sciences, authors define organizational ethnography as the study of human lives in organizations, with a particular focus on the social culture underlying the processes of organizing (Rosen, 1991; Van Maanen, 2002; Ybema et al., 2009). This methodological approach is particularly helpful in studying organizational practices, policies, processes, and dynamics (Bikker et al., 2017; Brant et al., 2018; Estabrooks et al., 2008; Liberati et al., 2015; Oliffe, 2005; Thomson, 2011; Cruz & Higginbottom, 2013). It aims to understand the experience of organizational actors in their natural context, with a particular interest in processes involved in shaping organizational culture (Cunliffe, 2010; Fine et al., 2009; Hammersley & Atkinson, 2007; Van Maanen, 2011). In recent qualitative studies that apply organizational ethnographic approaches in health care contexts, we observe an emerging methodological practice that combines organizational ethnography with case study design. This development has led scholars to question whether combining these approaches palliates the weaknesses and reinforces the strengths seen in each methodology, potentially improving the process and increasing the impact of qualitative health care research.
While previous research has focused separately on the methodological legitimacy of new forms of organizational ethnography and case study designs applied to health care research, little is known about why and when it is better to combine these two approaches (Baxter & Jack, 2008; Bryman & Buchanan, 2018; Carolan et al., 2016; Fine et al., 2009; Hammersley, 2018; Lambert et al., 2011; Ybema et al., 2009; Yin, 2009). Rodgers et al.’s (2016) methodological framework for organizational case studies provides methodological standards (13 items) for health care researcher who seeks to mobilize this methodology, has considerably contributed to advance the methodological conversation on this combined approach. Although the authors discuss the ethnographic origins of organizational case studies, they do not go so far as to propose, or argue, the combination of organizational ethnography and case study per se for health research (Rodgers et al., 2016). The lack of scientific benchmarks to support the choice of an appropriate study design represents a significant challenge to health care scholars. The aim of this article is to explore the methodological potentialities and limitations of combining organizational ethnography and case study approaches to conduct in-depth empirical research in health care. We begin by reviewing existing scholarship on what constitutes organizational ethnography and case study research before diving into their combination (see Table 1).
Description of Organizational Ethnographic and Case Study Designs.
What Is Organizational Ethnography?
There is currently no consensus on the definition of ethnography (Cunliffe, 2010; Hammersley, 2018; Hammersley & Atkinson, 2007; Rouleau, 2013; Van Maanen, 2006). According to Hammersley (2018, p. 1), delineating ethnography is difficult as this approach is often confused with broader qualitative research designs, interpretative approaches, fieldwork studies, and case study research. In addition, applications of ethnography draw on different epistemological, ontological, and ethical perspectives (Hammersley, 2018; Reeves et al., 2017; Ryan, 2017). This feeds ongoing debate over whether ethnography is a methodology, a theoretical approach, or both (Nugus & Forero, 2011; Thomson, 2011). In general, ethnography is the “study of human lives” in natural contexts (Hammersley & Atkinson, 2007, p. 1). The concept of culture is central (Clifford & Marcus, 1986). More specifically, organizational ethnography refers to the study of human lives in organizations, with a particular focus on the social culture underlying the processes of organizing (Rosen, 1991; Van Maanen, 2002; Ybema et al., 2009). It is especially interested in the organization and its materialization through human or nonhuman forms, including individuals, institutions, norms, processes, interactions, artifacts, and more (Dooley & Van de Ven, 1999; Fine et al., 2009; Hulst et al., 2017; Rosen, 1991; Cruz & Higginbottom, 2013; Yanow et al., 2009; Ybema et al., 2009). According to Fine et al. (2009, p. 602), organizational ethnography is an anthropological approach used since the 1950s to study “power, politics, informal relations, and resistance within organizations.”
What Is Case Study Research?
Challenges in defining the traditional case study approach arise from the confrontation between paradigms (Wahyuni, 2012), classic authors (Baxter & Jack, 2008), quantitative and qualitative approaches (Creswell, 2007; Villarreal Larrinaga, 2016), and empirical and theoretical applications (Aczel, 2015; Luck et al., 2006; Prévost & Roy, 2015). According to Prévost and Roy (2015, p. 135), the case study design is the “the most difficult type of research to define.” Yin (2014, p. 2) highlights the irony of scholars who characterize case study as a
What About Organizational Ethnographic Case Studies?
To the best of our knowledge, no study has yet provided a methodological definition of organizational ethnographic case study. As well, new adaptive forms of organizational ethnography have emerged in recent years such as focused ethnography, multisite ethnography, interorganizational ethnography, and rapid ethnography (Atherton et al., 2018; Beneito-Montagut et al., 2017; Berthod et al., 2018; Bikker et al., 2017; Falzon, 2016). These organizational ethnographic variations are often applied in combination with case study designs.
Focused Ethnography
Bikker et al. (2017, p.1) define focused ethnography as “a form of applied and pragmatic ethnography that explores a specific social phenomenon as it occurs in everyday life.” Many scholars argue that focused ethnography is particularly suited to study health care services, offering a legitimate approach to exploring various types of context, organizational cultures and subcultures, groups of actors, and sets of practices (Atherton et al., 2018; Bikker et al., 2017; Brant et al., 2018; Cruz & Higginbottom, 2013). Focused ethnography is distinguished from traditional ethnographic approaches as it is pragmatically applied, conceptually focused on a single organizational or social phenomenon, and fieldwork is conducted intensely over a short period of time (Bikker et al., 2017; Cruz & Higginbottom, 2013). Focused ethnography is often applied in more than one empirical site.
Multisite Ethnography
Multisite ethnography is defined by Flazon (2016, p. 1) as “the study of social phenomena that cannot be explained by focusing on a single site.” Given that health care systems and organizations often span multiple territorial boundaries, multisite ethnography is increasingly used to capture social or organizational phenomena that emerge and manifest in multiple settings simultaneously (Falzon, 2016; Marcus, 2011, 2012; Molloy et al., 2017). The goal of multisite ethnography is to better understand how processes, cultures, identities, and interactions flow simultaneously through different contexts in health care settings (Falzon, 2016; Molloy et al., 2017). This methodology is often empirically applied by multiple field researchers in several sites (Marcus, 2011; Yanow et al., 2009; Ybema et al., 2009). Molloy et al. (2017, p. 24) consider that, as yet, “multi-sited ethnography does not provide a strategy for designing studies.”
Interorganizational Ethnography
Interorganizational ethnography has increasingly emerged as a new form of social inquiry useful in studying social and organizational phenomena that manifest beyond organizational boundaries (Berthod et al., 2018; Van Maanen, 2011). This type of organizational ethnography requires researchers to explore phenomena in pluralistic settings and multiple organizational forms, both explicit and tacit, such as “events, language, rituals, institutions, behaviours, artefacts, and interactions” (Berthod et al., 2018, p. 2). The main goal is to explore interorganizational relations in all their forms, which involves paying attention to organizational boundaries (i.e., cognitive, geographic, hierarchic) that influence the context and ways in which organizational actors create and maintain relationships (Berthod et al., 2018). While interorganizational ethnography and multisite ethnography present some methodological overlap, there are differences in purpose: Interorganizational ethnography focuses on uncovering the interorganizational interactions that underlie a given social or organizational phenomenon, while multisite ethnography emphasizes contextualizing the social or organizational phenomenon per se, which develops simultaneously in pluralistic settings (Berthod et al., 2018; Molloy et al., 2017).
Rapid Ethnography
Rapid ethnography consists of applying the traditional organizational ethnographic approach in a compressed manner (Vindrola-Padros & Vindrola-Padros, 2017). In their systematic review, Vindrola-Padros and Vindrola-Padros (2017) argue that there is no consistent definition of rapid ethnography used in health care research. However, the authors provide five definitional criteria, which can be summarized as a densified application of ethnography that aims to explore “relevant social, cultural and behavioral information and focuses on human experiences and practices,” with a particular emphasis on the reflexivity of the research process (Vindrola-Padros & Vindrola-Padros, 2017, p. 19).
While there is increased interest in adaptive forms of organizational ethnography drawing on case study designs, few attempts have been made to investigate the advantages of combining these two approaches (Atherton et al., 2018; Beneito-Montagut et al., 2017; Bikker et al., 2017; Brant et al., 2018; Fine et al., 2009; Morgan-Trimmer & Wood, 2016). The need for clearer guidance in selecting appropriate methodologies to study questions in health care research led to a scoping review of the literature to explore the methodological potentialities and limitations of organizational ethnographic case studies.
Method
In conducting this scoping review, we used Arksey and O’Malley’s (2005) framework, which involves five stages: (a) identify the research question, (b) identify relevant articles, (c) select articles, (d) analyze the data from the articles, and (e) collect, summarize, and report the results. This method appeared relevant as it applies to a broad range of topics and disciplines in the health care field (Arksey & O’Malley, 2005). Our goal was not to assess the quality of papers. We essentially extracted data with the objective of identifying methodological potentialities and limitations raised in organizational ethnographic case studies.
Search Strategy
The search strategy was developed to answer the following research question: “What are the methodological potentialities and limitations of organizational ethnographic case studies used in health care research?” The search strategy involved various sources, including “search engines, electronic databases, reference lists, hand-searching of key journals, existing networks, relevant organisations and conferences” (Smith et al., 2016, p. 696). Searches were conducted on two search engines (EBSCOhost and Google Scholar) and seven databases (CINAHL, Academic Search Complete, Business Complete Source, PsycINFO, SocINDEX, MEDLINE, EconLit, and ERIC) using the following search terms: organizational ethnograph* OR organizational ethnograph* AND case stud* AND health OR health care. The first 10 pages of results from each search were examined (Arksey & O’Malley, 2005). In addition, we explored reference lists, hand-searched six specific journals (
Search Outcomes
Figure 1 illustrates the flowchart of the scoping review process, drawing on Smith et al. (2016, p. 698). The use of search terms in electronic databases led to 573 articles. Additional nonelectronic research through bibliographies, hand searching of key journals, textbooks, and relevant material added 73 articles, including mostly methodological papers (
Flowchart of the scoping review process.
Papers were excluded on full-text screening when their methodological design did not fit the purpose of our review. Most of these were identified as ethnographic case studies (
Charting Tables of Selected Articles: Methodological Potentialities of Organizational Ethnographic Case Studies.
Charting Tables of Selected Articles: Methodological Limitations of Organizational Ethnographic Case Studies.
Data Analysis
We used a two-phase analytical approach to extract and synthesize data from selected papers. First, descriptive analysis was used to categorize papers according to (a) author(s) and title, (b) research question/objectives, (c) study design, (d) case study selection/definition, (e) rationale for using the methodology, (f) data collection methods, (g) data analysis methods, (h) duration of fieldwork, (i) reflexivity, (j) methodological potentialities, and (k) methodological limitations. Second, we conducted an inductive thematic subanalysis of the methodological potentialities and limitations raised in each article, which led us to identify four methodological themes that embedded both the potentialities and limitations of organizational ethnographic case studies in health care contexts: (a) research process, (b) data sources, collection, and analysis, (c) credibility, and (d) impact of research. Each of these four themes embeds specific subthemes.
Descriptive and inductive thematic analyses were performed by the first author and were refined and validated through peer review by members of the research team (all three coauthors). Following each of three review cycles (submitted in the form of charting tables December 14, 2018, April 14, 2019, and October 6, 2019), the first author revised and refined the outcomes of the scoping review according to the feedback provided by the coauthors (Côté-Boileau et al., 2019, p. 3). Following this validation cycle, while it was not among the initial study objectives, recurrent insights emerging from analysis of the data allowed the research team (all authors) to inductively develop a matrix (see Figure 2) to describe the “methodological ‘winning combination’ of organizational ethnographic case study for in-depth qualitative health care research,” according to the four methodological characteristics mobilized to chart the selected literature for the scoping review. The development of the matrix unfolded into three steps: First, the first author inductively emerged individual methodological strengths respectively to organizational ethnography and case study designs. According to this analysis, the first author inductively emerged the combined methodological strengths of organizational ethnographic case studies. Second, all authors met (October 16, 2019) to refine and validate the results of this first inductive analysis. Third, all authors individually drew associations between (a) the four methodological characteristics and the individual methodological strengths of the two respective designs and (b) the individual methodological strengths of the two respective designs and their combined methodological strengths. All authors met (November 5, 2019) to refine and validate the final associations. All authors agreed that a new category emerged as what constitutes the “increased methodological power” of organizational ethnographic case studies applied in health care research.
Methodological matrix of organizational ethnographic case studies for in-depth qualitative health care research.
Results
While there is a significant body of research on the general strengths and weaknesses of qualitative research applied in health care, our review shows that specific potentialities (see Table 2) and limitations (see Table 3) arise from the combination of organizational ethnographic and case study research designs. In the following section, we aim to explain why these methodological specificities are meaningful for scholars wishing to undertake organizational ethnographic case studies in empirical health care contexts?
Methodological Potentialities of Organizational Ethnographic Case Studies Applied in Health Care Research
Research process
Organizational ethnography is distinguished by the depth, authenticity, and richness of knowledge it assembles and generates (Bikker et al., 2017; Bruni, 2006; Conte et al., 2017; Lalleman et al., 2015; McCourt et al., 2018; McCourt et al., 2014; Small, 2009; Swinglehurst & Greenhalgh, 2015; Swinglehurst et al., 2010; Vindrola-Padros & Vindrola-Padros, 2017). Moreover, organizational ethnographic approaches allow researchers access to unbounded organizational processes (e.g., organizational learning) that display either intra- or interorganizationally beyond tangible (e.g., geographic) boundaries, which often present in health care organizations (Falzon, 2016). Case study research, for its part, is distinguished from other qualitative designs by the deep contextualization of contemporary phenomena it provides. Case study research offers temporal, material, activity-based and contextual parameters to define cases, as “any phenomenon occurring in a delimited context” (Baxter & Jack, 2008, p. 545). Case study designs allow researchers to reveal contemporary phenomena based on similarities and differences between settings (cases), but also between competing social contexts, which are also highly characteristic of health care settings. Given these advantages, our review suggests that combining organizational ethnography and case study designs to study health care phenomena offers methodological reinforcement.
Merging organizational ethnography and case study offers an opportunity to access an in-depth contextualization of interorganizational (unbounded) multisite phenomena in various health care contexts. Greenhalgh et al. (2009), Greenhalgh et al. (2018), and Greenhalgh et al. (2008) have shown on numerous occasions that organizational ethnographic case studies provide unique tools to dissect how organizational processes in health care interact across multiple levels of context within and between sites and how these interactions produce organizational effects. While qualitative approaches generally allow a wide range of units of analysis (e.g., actors, behaviors, meanings, logics, processes, practices, routines, interactions, artifacts, contexts, boundaries), the in-depth immersion in multiple contexts and settings when undertaking organizational ethnographic case studies offers an exclusive opportunity to capture the organizational forms and effects of tacit knowledge that inhabit health care organizations. According to Cruz and Higginbottom (2013, p. 42), such studies “are holistic and have the ability to capture dimensions of the social world that are covert and tacit.” Combining the methodologies appears to provide a meaningful advantage for exploring the unexpressed yet significant knowledge that shapes organizational life in health care (Buchanan & Bryman, 2009; Hammersley, 2018).
Data collection
The triangulation of multiple data sources (e.g., observation, interviews, institutional documents, artifacts) is a methodological strength sought in all qualitative approaches to enhance both the credibility of the process and the impact of research. In organizational ethnography, the researcher is the main data collection instrument and aims to disturb the empirical field as little as possible (Fine et al., 2009; Van Hulst et al., 2017; Van Maanen, 2002; Yanow et al., 2009; Ybema et al., 2009). Ethnographic scholars therefore navigate the field with very little control over the research process. The aim of noninterference also explains why nonparticipant observation is traditionally the most valued data collection technique in ethnographic research (Atkinson & Hammersley, 1998). In case study approaches, researchers are encouraged to adapt their degree of control over the research process to the research goal (Yin, 2003, 2009, 2014). Combining organizational ethnography and case study can thus help structure the data collection process (e.g., identifying a priori moments of observation and units of analysis according to the research question) while still not disturbing or influencing the empirical field (e.g., focusing on observation as the primary data collection technique; Bikker et al., 2017; Molloy et al., 2017). Because organizational ethnographic case study designs in health care are often applied in multiple settings, data collection is usually conducted in teams with multiple field researchers (Beneito-Montagut et al., 2017; Bikker et al., 2017; Jarzabkowski et al., 2015). Combining these two methodologies appears to provide a meaningful advantage by structuring and accelerating the empirical research process without compromising the depth and quality of data.
Data analysis
While qualitative research is by definition a thorough and creative process, the combination of organizational ethnographic and case study designs takes the “flexibility” of qualitative data analysis to another level. Organizational ethnographic researchers traditionally mobilize an inductive analytical approach, which is often an unstructured process. According to Hammersley and Atkinson (2007, p. 3), “Data analysis involves the interpretation of the meanings, functions and consequences of human actions and institutional practices, and how these take place in micro and macro contexts.” Case studies support both inductive and deductive analysis as well as intra- and intercase analytic strategies (Gerring, 2006; Stake, 1983, 1995; Yin, 2014). In a combined approach, analysis may be structured while preserving the flexibility proper to organizational ethnography (Bruni, 2006; Lalleman et al., 2015; McCourt et al., 2012; Swinglehurst & Greenhalgh, 2015; Swinglehurst et al., 2010). Working with cases and delimited units of analysis helps researchers conduct data collection alongside analysis by means of an organized database, opening opportunities for multi-context analysis, in-depth intracase analysis, and intercase comparative analysis. Moreover, case study approaches offer several analytical techniques (e.g., matrices, conceptual mapping, diagrams) that can be used to expand the possibilities for analyzing ethnographic data (Miles et al., 2013; Prévost & Roy, 2015). Combining these two methodologies appears to provide a meaningful advantage to accelerate and enrich data analysis over the course of data collection, extract the maximum out of massive ethnographic data pools, and make sense of research findings.
Credibility
Our scoping review suggests that the active role of the researcher and the emphasis on reflexivity in organizational ethnographic case studies may enhance the credibility of this design. Berthod et al. (2018) argue that the richness of the researcher’s experience in the field is more important than the length of time spent on site. The fact that organizational ethnographic case studies often involve multiple sites provides an opportunity to access and integrate the various reflexive experiences of multiple fieldworkers to inform and enrich the research (Bruni, 2006; Greenhalgh et al., 2008; McCourt et al., 2012; Molloy et al., 2017). Moreover, Prévost and Roy (2015) suggest that the quality of case sampling in organizational ethnographic case studies enhances methodological credibility. Both methodological approaches value a multiplicity of subjective perspectives as a source of credibility. While reflexivity and sampling strategies feature in other qualitative approaches, the powerful complementarity between contextualized sources of data and reflexivity achieved by combining organizational ethnography and case study reinforces the credibility of the research process.
Impact of research
Given that data analysis in organizational ethnographic research is iterative, thorough and long, many scholars consider it difficult to generate timely and actionable knowledge with this methodology. This challenge is especially important in health care organizations that are characterized as rapidly changing environments (Côté-Boileau et al., 2019). The organizational needs and concerns that motivated acceptance of an ethnographic research project may well change before research is complete. As well, the researcher is expected to maintain a degree of “neutrality” and reflexivity while immersed in the field. These factors make it challenging to engage in knowledge transfer activities during the research process, as data have yet to be analyzed, and such activities create ambiguity around the researcher’s role (Hammersley, 2018; Liberati et al., 2015). However, the empathic closeness to organizational life that scholars develop enables trust-building to generate partnerships with stakeholders. The case study approach helps to delimit and accelerate fieldwork, allowing findings to be communicated in a timely manner to meet stakeholders’ needs. Some authors also argue that combining case study with organizational ethnographic design enhances the capacity to generalize results, given that it enables deep exploration of multiple social contexts within and between organizations (Berthod et al., 2018; Bikker et al., 2017; Falzon, 2016; Marcus, 2011, 2012; Molloy et al., 2017). In addition, case study methodologies provide techniques for empowering research participants in knowledge transfer. Along with enhancing the impact of research, combining the two methodologies allows for more significant theoretical development. The importance placed on in-depth investigation and understanding of a phenomenon in its natural context in ethnographic studies, coupled with the rigor around units of analysis and sampling strategies in case study research, increases theoretical potential. Combining these two methodologies appears to provide a meaningful advantage in terms of both knowledge transfer and theoretical development to increase the impact of research in health care organizations.
The analysis presented above reveals important potentialities in combining case study and organizational ethnography approaches in the health care context. In this next section, we will address findings from the scoping review that point to limitations this hybrid methodology implies for health care researchers.
Methodological Limitations of Organizational Ethnographic Case Studies Applied in Health Care Research
Research process
The immersion of researchers in empirical fields is a methodological foundation and strength in organizational ethnography but raises challenges when combined with case studies. Immersion requires that the researcher first gains access to the field. Several scholars describe accessing the field in ethnographic studies as a continuous “time-emotions-energy-consuming” negotiation (Alcadipani & Hodgson, 2009; Bell, 2010; Bengry-Howell & Griffin, 2012; Bruni, 2006; Enguix, 2014). This process requires trust between researchers and organizational stakeholders. Moreover, given the plurality and size of health care organizations, the gatekeepers with whom a researcher negotiates access may not even be among the actors involved or “affected” (e.g., observed, interviewed) by the research (Hammersley, 2018; Vindrola-Padros & Vindrola-Padros, 2017). In organizational ethnographic case studies involving multiples settings and conducted by multiple fieldworkers, it may be more difficult to establish and maintain trusting relationships. As well, significant time and resources are required to train fieldworkers (Bikker et al., 2017; Greenhalgh et al., 2008; Vindrola-Padros & Vindrola-Padros, 2017). These considerations challenge the feasibility of organizational ethnographic case studies but also raise issues around the researcher’s role.
Having multiple fieldworkers collecting data simultaneously or sequentially complicates the role of researchers as either “insiders or outsiders” to the organizations they study (Berthod et al., 2018; Bikker et al., 2017; Bruni, 2006; Marcus, 2011; McCourt et al., 2012; Molloy et al., 2017). Variations in trust and emotional roller coasters enter the equation (Benoot & Bilsen, 2016), and ethical gray zones appear.
In addition to complicating ethical issues related to the informed consent of participants in ethnographic approaches, organizational ethnographic case studies require that potential bias be controlled in not one, but several fieldworkers. Fieldworkers immersed in health care organizations are exposed to organizational realities, power struggles, personal distress, and more (Alcadipani & Hodgson, 2009; Enguix, 2014; Fine & Shulman, 2009). It can become hard not to “advocate” for the people facing the difficulties witnessed (Hammersley, 2018). According to Ybema et al. (2009, p. 187), “ethnographers are often motivated to give a voice to participants, but they cannot reveal information that could harm the organization.” It is challenging for scholars to ensure that their passage in an out of research fields is ethical (Swinglehurst et al., 2010). Combining the two methodologies presents a disadvantage by lengthening and complicating the process of negotiating access to the fields, managing the researcher’s role, and addressing ethical issues.
Data collection and analysis
While the triangulation of data sources through organizational ethnographic case study research is a methodological strength, exploiting the mass of data generated must be approached carefully. It is easy to become overwhelmed and “get lost” in the forest of data (Baxter & Jack, 2008; Fine et al., 2009). Moreover, numerous empirical studies suggest that combining organizational ethnography with case studies can induce confusion between units and levels of analysis and cases (Bruni, 2006; Greenhalgh et al., 2018; Greenhalgh et al., 2008; Swinglehurst et al., 2010). The dispersion and diversity of health care organizations raise challenges for fieldwork, given that organizational cultures, identities, and processes are no longer “geographically” bounded. Cruz and Higginbottom (2013, p. 42) considers that, The fluidity of boundaries in ethnographic health care research may be regarded as a lack of exactitude and robustness by those who view ethnography from a positivistic perspective, which is underpinned by objectivity rather than subjectivity.
Credibility
One obvious but significant challenge in establishing the credibility of organizational ethnographic case studies is the lack of methodological benchmarks that define this design. It is difficult to ensure the validity of both case sampling strategies and fieldwork techniques involved in this methodology (Bikker et al., 2017; Bruni, 2006; McCourt et al., 2014; Molloy et al., 2017; Swinglehurst et al., 2010; Vindrola-Padros & Vindrola-Padros, 2017). Some authors argue that theoretical sampling in organizational ethnographic case studies helps to increase methodological validity (Fine et al., 2009; Goulding, 2005; Palinkas et al., 2015). Critics question the legitimacy of fieldwork in adapted ethnographic methodologies (e.g., multisite ethnography, interorganizational ethnography, rapid ethnography, team-based ethnography), considering this “disrespectful” to the very foundations of this methodology; deep understanding of the experience of organizational actors in their natural context traditionally requires immersion of a single researcher in a specific field for a significant time period. While Berthod et al. (2018, p. 17) argue, on the other hand, that “Obsession with richness in data should not be the reason for conducting ethnography” and that the duration of fieldwork should not be considered a guarantee of methodological quality or analytic saturation. We found no existing methodological counters to this argument. There is increasing evidence that emotions influence ethnographic processes in health care research (Benoot & Bilsen, 2016; Gelling, 2014; Hammersley, 2018; Lambert et al., 2011; McCourt et al., 2012, p. 20122; Rosen, 1991; Simmons, 2007; Cruz & Higginbottom, 2013). Although emotions can be accommodated through reflexivity, a multiplicity of fieldworkers in organizational ethnographic case studies may spread the effect of emotional dynamics across the research process. Combining the two methodologies appears to present a disadvantage, as there is a lack of methodological benchmarks to support the credibility of this research design.
Impact of research
Questions around the generalizability of results from qualitative research go beyond organizational ethnographic and case study research. However, as previously mentioned, authors have different views on whether the capacity to generalize results is enhanced when organizational ethnography and case study are combined. Prévost and Roy (2015) claim that while organizational ethnographic case study offers the possibility of deeply exploring organizational phenomena embedded in various social contexts, it also harms intracase depth and quality. In addition, given the lack of methodological benchmarks to define organizational ethnographic case study, Bikker et al. (2017) argue that it is difficult to find and/or design dissemination strategies appropriate to this combined methodology. Our review reveals that authors sometimes find it difficult to get support from universities and funding bodies for this kind of research (Molloy et al., 2017; Vindrola-Padros & Vindrola-Padros, 2017), given the duration of fieldwork, the resources it requires and the difficulty of quickly generating and disseminating results. Combining these two methodologies appears to provide a meaningful disadvantage as it dilutes intracase analytical depth, even as it benefits deep intercase analysis.
Discussion
What Makes Organizational Ethnographic Case Study the Right Choice for In-Depth Qualitative Empirical Research in Health Care?
Our scoping review reveals that organizational ethnographic case studies appear as an emerging in-depth qualitative methodology for health care research, which involves specific methodological potentialities and limitations. Drawing on our scoping review, the following section aims to illustrate a methodological matrix (see Figure 2) that can serve as a rationale for health researchers who wish to investigate organizational phenomena in real contexts.
In-Depth Closeness to Competing Organizational Lives
Molloy et al. (2017) argue that organizational ethnographic case studies are a relevant and generative approach to deeply access the coexisting social worlds that populate health care organizations. According to the authors, health care researchers who embark in this methodology embrace a more active role in the knowledge production process, as they “construct rather than discover” empirical sites (Molloy et al., 2017, p. 5). In addition, McCourt et al. (2014, p. 86) suggest that this combined methodology “may often be important for generating hypotheses and for investigating in more depth the ‘how’ and ‘why’ questions posed in research around organisation of care.” To this end, in a 2018 study of real-world implementation of video outpatient consultations at various institutional levels of the health care system (macro, meso, and micro) in the UK, Greenhalgh et al. (2018) show that using an organizational ethnographic case study design allowed them to capture and understand the “messy realities” of organizational life in health care. More precisely, this specific design allowed researchers to reveal how various institutional contexts interact and compete with each other through the scaling of technological innovations. Kerosuo’s (2010) study on how patients with multiple and chronic illnesses experience interorganizational care reveals that organizational ethnographic case studies offer a unique opportunity to access several local experiences and understand how they connect to produce different organizational effects in health care. To the same point, Liberati et al. (2015) show that immersion in multiple social worlds through organizational ethnographic case studies offered a unique opportunity for researchers to understand how daily practices contributed to the local enactment of patient centeredness. This study also demonstrates how deep contact with multiple organizational lives helps reveal new forms of agency (e.g., shared agency between human and nonhuman actors) in health care, calling for more research studying organizational phenomena in health care from a sociomaterial perspective. Bruni (2006) argues that health care services must be studied as trajectories rather than discrete events, highlighting the need for researchers to negotiate access to multiple field sites. Researchers undertaking organizational ethnographic case studies constantly move across social worlds, enabling them to uncover situated patterns and relationships that underlie the cultural construction of meaning and action in health care organizations and build stronger analytical narratives (Bruni, 2006; Swinglehurst & Greenhalgh, 2015). In sum, by combining organizational ethnography and case study, researchers access a privileged and deep closeness to competing organizational lives, which, according to many scholars, also enables the generation of timely actionable and contextualized knowledge to inform, and transform, health care practices and policies.
Timely Actionable and Contextualized Knowledge Production
Our scoping review finds that organizational ethnographic case studies applied in health care contexts offer enabling methodological conditions to generate actionable and contextualized knowledge in a timely manner during the research process. A scoping review by Vindrola-Padros and Vindrola-Padros (2017, p. 1) concludes that this kind of approach is especially “appealing to the health care sector, where changing organisational climates and priorities require actionable findings at strategic time points.” Likewise, Liberati et al.’s (2015) study demonstrates that by capturing multiple contextualized sources of data, organizational ethnographic case studies allow researchers to disseminate findings as research progresses that are valuable to participants and inform practices and decisions. Bikker et al.’s (2017, p. 1) research on primary care general practices in the UK also shows that organizational ethnographic case studies applied in health care “provide timely findings within the fast-moving context of health care policy and research.” This combined methodology appears to offer creative methodological and analytical entry points to understand the social and cultural factors that shape health care delivery, which enhances the richness of fieldwork and the capacity to “generate findings that can inform changes in healthcare practices in a timely manner” (Vindrola-Padros & Vindrola-Padros, 2017, p. 2). By offering conditions that support a fieldwork journey that is both thorough and structured (e.g., delimiting empirical sites, cases, units of analysis), organizational ethnographic case studies also increase the potential to build productive, yet sustainable, partnerships between researchers and participants (Bikker et al., 2017; Bruni, 2006; Molloy et al., 2017; Ruelland, 2015; Swinglehurst et al., 2010). This methodology offers the opportunity to empower participants through the research process and therefore enables a joint understanding to emerge between stakeholders, opening meaningful avenues for empirical health care research.
Contextualized Multilevel Interactions and Variations
According to Molloy et al. (2017, p. 13), organizational ethnographic case study “is more relevant to the interconnected world of health and healthcare.” In their study on how population health information management systems in Australia intersect with health promotion practice, Conte et al. (2017) show that the combined methodology provides particular contextual information on each empirical site that enabled researchers to explore and understand the interactions and variations within and across cases. The authors argue that this methodological advantage enhances the capacity to generalize results from organizational ethnographic case studies in health care. Greenhalgh et al.’s (2008, p. 8) exploratory study of the introduction of a centrally stored shared electronic patient record in England found that organizational ethnographic case study offered a context-sensitive research design that allowed them to “document how interactions at these multiple levels shape, enable, and constrain the introduction of technology supported innovations in clinical care.” Kerosuo (2010) and Liberati et al. (2015) likewise propose that this methodology offers a unique entry into the complex interactions between practices, technologies, professionals (collegiality), and power boundaries that shape integrated care in public health systems. In addition, McCourt et al. (2012), in their exploratory study of organizational and professional issues that influence the quality and safety of care in different birth settings in the UK, argue that organizational ethnographic case studies offer a better understanding of how organizational practices are shaped by institutional relationships. Given that health care organizations are highly pluralistic and institutionalized environments, the authors point to the importance of looking at the experience of organizational actors in relation to the institutional level (context) in which processes, information flow, meaning, and action unfold. Organizational ethnographic case studies appear as a powerful methodology in this endeavor. Moreover, by exploring the role of information and communication technologies in shaping collaborative work routines in the UK health care system, Swinglehurst et al. (2010, p. 3) reveal that organizational ethnographic case study challenges ethnographic paradigms by alternating the focus “between studying the work of individuals within a particular routine, the overall routine, and the wider organisational context, with reflexive awareness of the dynamic interplay between parts and wholes.” The authors call for more research using this methodology to uncover the micro sources of influence at multiple levels that underlie intra- and interorganizational phenomena in health care settings. In short, organizational ethnographic case study emerges as a powerful and innovative methodology to reveal “how parts of the contemporary healthcare worlds interact and operate” across levels in health care systems (Molloy et al., 2017, p. 13).
Situated and Shared Reflexive Experiences of Multiple Fieldworkers
The collective engagement of researchers and participants in reflexivity can help disentangle and bring to surface the tacit knowledge spread in everyday care practices and transform it into actionable knowledge, namely a kind of knowledge that is ready to be put into practice. (Liberati et al., 2015, p. 51)
In line with this statement from Liberati et al. (2015), our scoping review shows that many authors highlight the significant strength that comes from assembling the situated reflexive experiences of multiple fieldworkers in organizational ethnographic case studies. In addition to accelerating fieldwork, the involvement of multiple fieldworkers increases the ability to identify, acknowledge, and resolve contradictions between data sources and reflexive experiences and thereby disrupt assumptions and better understand the influence of intra- and interorganizational characteristics in shaping organizational phenomena (Bikker et al., 2017; Greenhalgh et al., 2009; Liberati et al., 2015; Molloy et al., 2017; Ruelland, 2015). It essentially helps to generate a more holistic understanding of a given phenomenon. Moreover, given that collaboration is at the heart of team-based ethnographic approaches, ongoing dialog between multiple fieldworkers can provide practical and emotional support throughout the research process and building trust between research team members and research participants (Bikker et al., 2017; Marcus, 2011). Bruni (2006) and Swinglehurst (2015) argue that the inherent and intrinsic relationships between fieldworkers and sites help to build narratives that address the local particularities of each empirical context. The complementary situated reflexive experiences of multiple fieldworkers enables organizational ethnographic case study to track and recognize the dynamism of health care organizations in meaningful and productive ways, rather than aiming to control it.
Conclusion
This scoping review makes it clear that organizational ethnographic case studies have features that distinguish them from the wider domain of qualitative health care research. By combining organizational ethnographic approaches and case study designs, health care researchers achieve greater depth, more refined contextualization, and increased credibility and impact in their empirical qualitative studies. Our review also reveals that the specific potentialities and limitations raised by organizational ethnographic case studies do not simply mirror each other. The central methodological advantage of this approach is in offering a unique opportunity to deeply explore, with multiple reflexive experiences, contextualized complex organizational phenomena in health care. The most significant disadvantage lies in the current lack of methodological benchmarks to support the validity of this methodology, which limits support for the considerable resources it requires. This also presents challenges for teaching the approach and encouraging its use in health care research. However, our review leads us to believe that by accelerating the pace of research, empowering various sources of reflexivity, and increasing the depth of empirical investigation of complex organizational phenomena, this combined methodology might inform a new generative agenda for qualitative research in health care. Moreover, in response to Bryman and Buchanan’s (2018) critique of methodological conservatism in organization studies, organizational ethnographic case study may nourish a greater academic dynamism to increase the impact of our research on the lives of health care organizations, and most importantly, of the people within them. An especially promising place for future research using this combined methodology is in studying how the role and impact of emergent technologies and innovations in health care are shaped by competing social contexts along their journey through the complex interconnected worlds of health care.
Footnotes
Authors’ Note
While Susan Usher did not participate in the writing of the article per se, her editing services were fundamental in the publication process of this article.
Acknowledgment
The authors would like to thank Susan Usher for the edition of this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research received funding from the Fonds de recherche du Québec—Santé for the period of September 2017 to August 2020, as part of an ongoing doctoral study (file number 35869).
